Coordinated Assessment Referral and Evaluation System

Creating a more effective and efficient homeless response system


CARES is designed to enhance the quality of client screening, assessment, and tracking, in order to more effectively link to and prioritize homeless resources. As a result, the system for preventing and ending homelessness is less fragmented, more strategic, and scarce resources are used more efficiently.

This work cannot happen alone. CARES is a collaborative initiative of the North Dakota Continuum of Care, the North Dakota Coalition for Homeless People, the West Central and Continuum of Care, the Fargo-Moorhead Coalition for Homeless Persons, and the White Earth Nation.


CARES works to:

  • Help simplify and speed the process for people to accurately locate and access needed services;
  • Help improve the equality and accessibility of services;
  • Help to ensure that people get the right services;
  • Save people precious time in looking for and traveling to various service sites or filling out multiple service applications;
  • Allow staff to focus more on serving clients and less on gathering information and filling out forms;
  • Support interagency collaboration and coordination around a single process; AND
  • Improve cost efficiency by replacing duplicative intake and assessment functions with a single approach and data sharing.



The lack of a common coordinated entry system with a standardized assessment created inefficiency and frustration for households experiencing and at-risk of homelessness and for providers of homeless services.

Prior to CARES, families navigated an obstacle course of different phone numbers, agency vacancy protocols, and intake criteria in order to get assistance. Locating resources could be random for the family and did not always lead to the best fit for their needs. It was a stressful process for vulnerable families and especially for families with higher needs (who probably do not fare as well). In the previous system, a homeless family or individual could find shelter in a few days, or it could take weeks or months, depending on who they called, how often they called, and so on.

In addition, system-wide, very little was known about families and individuals that were being turned away or who did not seek services. It was not possible to target resources to program areas based on unduplicated need or demand for services.

More than three years of research and development at multiple sites has culminated in the creation of CARES.


CARES provides:

  • A clearly identified process for families and individuals to know where and how to access services.
  • A standardized and centralized access points to request services. Without additional resources within the system, families may not access services more quickly; however they will not need to continuously navigate the obstacle course of making numerous calls without knowing if or where they will find assistance.
  • A standardized assessment - the ability to match families into appropriate housing and services tailored to their needs. Through one process, families will have access to a variety of programs that would be suitable for them based on their housing and service needs.
  • Coordinated referrals at a system-wide level that matches families with the most appropriate services and providers based on the standardized assessment of the family and the program eligibility.
  • Unduplicated data on the number of homeless families and the needs/barriers of these families that can influence system modifications and enhancements. For example, information on how many families are seeking services, what are their service level needs, what is the wait time for families receiving services (system gaps), etc.
  • The result is a system for preventing and ending family homelessness that is less fragmented and is more efficient and effective for families.



  1. Reorient service provision, creating a more client-focused environment.
  2. Identify which strategies are best for each household based on knowledge of and access to a full array of available services.
  3. Link households to the most appropriate intervention that will assist the household to resolve their housing crisis.
  4. Provide timely access and appropriate referrals to housing programs and support services.
  5. Shorten the number of days between onset or threat of homelessness and access to prevention or re-housing services.
  6. Provide immediate access to information regarding housing and support services.
  7. Create an advanced system designed to provide the best client outcomes.
  8. Collaborate when possible with adjoining Continua of Care and tribal entities.
  9. Provide for ongoing participation by consumers and stakeholders in the development and evaluation process of coordinated assessment.
  10. Tribal Sovereignty is acknowledged and honored.



CARES is governed by a board elected from members of the participating two continua of care, with one member specifically designated to represent the Fargo-Moorhead Coalition for Homeless Persons. The collaborative group was formed via a Memorandum of Understanding

Current governance board members are (as of April 2016)


North Dakota Continuum of Care

Mark Heinert, Programs Director, Youthworks, Bismarck and Fargo

Heather Ingman, Advocate, Domestic Violence and Rape Crisis Center, Dickinson, ND

Deb Johnson, Executive Director, Prairie Harvest Mental Health, Grand Forks, ND

Tana Johnson, Homeless Case Manager, Badlands Human Service Center, Dickinson, ND

Janelle Moos, Executive Director, North Dakota Abused Women’s Services, Bismarck, ND

Mac McLeod, Executive Director, Minot Area Homeless Coalition


West Central Minnesota Continuum of Care

Sonja Ellner, Executive Director, Dorthy Day House of Hospitality, Moorhead, MN

Becki Johnson, Director of Family & Community Services, Lakes and Prairies Community Action Partnership, Moorhead, MN

Dara Lee, Executive Director, Clay County Housing and Redevelopment Authority, Dilworth, MN

Heather Molesworth, Family & Commuinty Services Director, West Central Minnesota Commuinty Action, Elbow Lake, MN

Marcia Otte, Family Development Director, Mahube-Otwa Comuinty Action, Detroit Lakes, MN

One seat currently open, TBA


Fargo-Moorhead Coalition for Homeless Persons

Jill Elliot, Deputy Director, Fargo Housing and Redevelopment Authority, Fargo, ND


White Earth Nation 

Kristi Dawes, Homeless Housing Coordinator, White Earth Nation


Advisory members (non-voting):

Laurie Baker, Executive Director, FM Coalition for Homeless Persons

April Fairfield, Executive Director, North Dakota Coalition for Homeless People

Darrin DJ Gahner, HMIS Administrator, North Dakota Coalition for Homeless People

Diana Hall, Veterans Administration

Adele Siegel, Program Administrator, North Dakota Department of Commerce

Carla Solem, Coordinator, West Central Homeless to Housed Taskforce

Cody Schuler, Program Coordinator, Coordinated Assessment, Referral and Evaluation System